Departments of Orthopedic Surgery (M.T.H., E.R.W., C.C.W., A.D.H., M.J.T., and S.L.M.) and Biostatistics and Health Sciences Research (W.S.H.) and Division of Plastic and Reconstructive Surgery (S.L.M.), Mayo Clinic, Rochester, Minnesota.
J Bone Joint Surg Am. 2018 May 16;100(10):850-856. doi: 10.2106/JBJS.17.00156.
Deficient soft tissue following total knee arthroplasty (TKA) can jeopardize outcome. The gastrocnemius flap is an important means of providing coverage of a knee with deficient soft tissue. There is a paucity of long-term studies on the use of the gastrocnemius flap in the setting of TKA. The purpose of this study was to review the outcomes after the use of pedicled gastrocnemius flaps for coverage of a soft-tissue defect at the time of TKA.
Eighty-three patients in whom a gastrocnemius flap had been used to cover the site of a primary (n = 18) or revision (n = 65) TKA over a 25-year period were identified. There were 48 women (58%) and 35 men (42%) with a mean age and body mass index (BMI) of 65 years and 32.6 kg/m. The mean wound size was 49 cm, and the wound was most commonly located over the anterior aspect of the knee/patellar tendon (n = 33). Patients were followed to the time of implant or flap revision, amputation, or death or for a minimum of 2 years (mean, 8 years). Clinical outcomes were assessed using the Knee Society Score (KSS) for pain and the KSS for function. The Kaplan-Meier method was used to assess revision and amputation-free survival. Risk factors for amputation and revision were identified with Cox regression.
The 10-year revision and amputation-free survival rates following gastrocnemius flap coverage were 68% and 79%, respectively. The risk of implant failure was increased by morbid obesity (BMI of ≥40 kg/m) (hazard ratio [HR] = 2.82, 95% confidence interval [CI] = 1.09 to 7.32, p = 0.03) and ≥5 prior surgical procedures on the knee (HR = 2.68, 95% CI = 1.04 to 6.88, p = 0.04). The risk of amputation was increased in patients with ≥5 prior surgical procedures (HR = 10.76, 95% CI = 2.38 to 48.58, p = 0.002), an age of ≥65 years (HR = 4.94, 95% CI = 1.10 to 22.09, p = 0.03), and a wound size of ≥50 cm (HR = 3.29, 95% CI = 1.14 to 9.53, p = 0.02). Preoperatively the mean KSSs for pain and function were 46 and 28, and these scores significantly (p < 0.05) improved to 78 and 43, respectively, at the time of follow-up.
The gastrocnemius flap reliably provides coverage of components used in complex knee reconstruction. A history of multiple surgical procedures on the knee and larger soft-tissue defects increase the risk of revision TKA and of amputation.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
全膝关节置换术后（TKA）软组织缺损会影响手术效果。腓肠肌皮瓣是覆盖膝关节软组织缺损的重要手段。关于 TKA 中使用腓肠肌皮瓣的长期研究较少。本研究旨在回顾使用带蒂腓肠肌皮瓣覆盖初次（n=18）或翻修（n=65）TKA 时软组织缺损的结果。
回顾性分析了 25 年间，83 例 TKA 中使用腓肠肌皮瓣覆盖的患者。48 例女性（58%）和 35 例男性（42%），平均年龄和体重指数（BMI）分别为 65 岁和 32.6kg/m²。平均伤口大小为 49cm，伤口最常见于膝关节/髌腱前侧（n=33）。患者随访至植入物或皮瓣翻修、截肢或死亡或至少 2 年（平均 8 年）。使用膝关节学会评分（KSS）评估疼痛和功能的临床结果。Kaplan-Meier 方法评估皮瓣翻修和截肢的无失败生存率。使用 Cox 回归确定截肢和翻修的风险因素。
腓肠肌皮瓣覆盖后 10 年的皮瓣翻修和截肢无失败生存率分别为 68%和 79%。病态肥胖（BMI≥40kg/m²）（HR=2.82，95%置信区间[CI]：1.09-7.32，p=0.03）和≥5 次膝关节手术（HR=2.68，95%CI：1.04-6.88，p=0.04）增加了植入物失败的风险。≥5 次膝关节手术（HR=10.76，95%CI：2.38-48.58，p=0.002）、年龄≥65 岁（HR=4.94，95%CI：1.10-22.09，p=0.03）和伤口大小≥50cm（HR=3.29，95%CI：1.14-9.53，p=0.02）会增加截肢风险。术前，疼痛和功能的 KSS 平均分别为 46 和 28，随访时分别显著（p<0.05）改善至 78 和 43。
腓肠肌皮瓣可靠地为复杂膝关节重建提供覆盖。膝关节多次手术史和较大的软组织缺损增加了 TKA 翻修和截肢的风险。
治疗性 IV 级。有关证据水平的完整说明，请参见作者说明。
